Category Archives: Bioethics

Bhaven Sampat has written a review of our text in Global Public Health 8(2):236-9, 2013. His summary judgment is:

Having expressed some minor complaints, I emphasise that I like the book and recommend it. I have long been interested in teaching a course on cost-effectiveness analysis that goes beyond technique and engages some of the political and ethical issues behind the scenes. This volume would be a good introduction to these themes in the context of prevention and treatment. The first three chapters would also provide a very good short introduction to the prevention versus treatment debates for policymakers and others interested in a general overview of these issues.

The first three chapters include the introduction (Faust and Menzel), economics (Altarum Institute – Miller, Roehrig, Hughes-Cromwick, and Turner), and cost-savings/effectiveness (Russell). We’re pleased he liked these chapters and they tend to be the most quoted of the chapters on policy-related blogs.

Let’s look at his “minor complaints.”

First, he doesn’t think the third section of the text, on how religious perspectives look at the balance, are valuable. “Though these chapters provide a useful introduction to medical ethics issues from different traditions, I do not think they connect well with the other chapters or speak to the balance question.” Given that other reviewers have praised the connectedness of the chapters, I’d like to better understand what he means by that portion of his comment. But more importantly, his “speak to the balance question” comment is puzzling. Each chapter in the third section specifically looks at how each religion represented considers how to balance prevention and treatment. The problem is that, except for Seventh Day Adventism (SDA), they all come out on the side of treatment without actually making the comparison in their religious texts or commentaries, except as gleaned from isolated statements.

This was surprising to Paul and me as well – none of Protestantism, Catholicism, or Judaism explicitly address the balance between treatment and prevention. This is the interesting finding from this section. When pushed, the authors of these chapters, who originally all stated there is no preference stated, eventually intuited that indeed treatment is commanded to take precedence in most instances (except in the “community elders” argument of Judaism). And even when Roy Branson’s chapter on SDA went a little deeper he found it easy to conclude that while prevention was still very important historically and theologically, there could be some concern that the SDA treatment system, which today is one of the largest in the US, is overwhelming in its use of resources, worrying that it could crowd out the prevention orientation.

Perhaps Sampat thought that they don’t address the balance question because indeed within the traditions they don’t explicitly address it, and he confused that with not asking or addressing the question within the chapters?

To the second minor complaint I plead guilty: I approached the book originally with the strong bias that prevention is underfunded and we don’t devote sufficient attention to it in policymaking or in the clinic. The latter is demonstrable with the under-use of prevention resources, even those considered cost-saving and cost-effective. This bias was stated explictly in the introduction, wherein Paul and I illustrate this underfunding and under-attention emphasis in various settings and the US’ clear bias toward treatment and away from prevention. This has been my stance throughout my career and I still believe it correct. And here is how I believe, from a policy perspective, this conclusion is dispositive: everyone talks about how treatment care costs too much – and by “health care” they usually mean “treatment” care. And everyone talks about how we don’t do enough in prevention. Yet we continue to pay for treatment care (almost at any cost) even when we know that additional dollars to prevention could help (but not cure) under-utilization of prevention. I address this in chapter 6 of our text, where I point out that funding alone (e.g. first dollar funding of prevention by the Affordable Care Act) won’t fix the access and other issues associated with successful prevention for individuals and communities.

Having said this, Sampat would be surprised to find how much my own view and public stances on prevention have changed since beginning the book. Now instead of speaking in full defense of prevention I add nuances of concern and reality. I even have one talk, “The Moral Problem of Prevention,” where I explicitly point out these concerns and why prevention might not take the theoretical moral high road which it used to take.

I agree also with Sampat’s concern that we didn’t spend more time on both the politics of prevention (mostly just covered in Diana Petitti’s chapter) and how the values-attitudes mix impacts both policy and individual decision-making. I call for more imagination in effecting the “affect heuristic” in prevention – we need to figure out how we can evoke better future suffering because of a lack of prevention in order to have decision-makers understand better their effects when they don’t fund prevention. Indeed the theme of the American College of Preventive Medicine’s 2015 meeting will be just that – Imagination in Preventive Medicine, from a policy and delivery perspective.

Generally those who practice prevention both in the public health and private clinical spheres have not been very good at marketing health to their stakeholders. Certainly marketing techniques like those used for unhealthy products and services have evolved into fine arts – glossy well-designed corporate annual reports, while many public health programs still use the equivalent of xeroxed, hand-folded brochures. We need to find efficient, effective ways to deliver better messages, motivate people in different directions, and change tastes (literally).

Perhaps Paul Menzel and I will produce volume 2, which would address some of Sampat’s minor complaints. Maybe he’d like to explore the political context more? We would have liked to have addressed some of his complaints in our first volume, but frankly were concerned about going over 400 pages for practical publication purposes.

The US Preventive Services Task Force published their final recommendation update on PSA screening to detect early prostate cancer. The USPSTF is the most unbiased and science-based organization in the US. It is free from bias, and scrupulously maintains a strict conflict of interest policy. It’s members do not have a financial interest in the outcome of the analyses done, like the American Urological Association might have for PSA testing, nor do they have a conflict of commitment – a worldview that catching cancer early is a prime overwhelming driving force, like the American Cancer Society has had in the past. (I think the ACS has been much more nuanced and reasoned in their responses in the past few years as compared with the past.) The AUA has announced that it is “outraged and believes that the Task Force is doing men a great disservice by disparaging what is now the only widely available test for prostate cancer, a potentially devastating disease.” I think the AUA is wrong, and that the USPSTF’s recommendation is more balanced and reasoned than the AUA states.

Basically the USPSTF claims that there are reasons not to screen for prostate cancer using current techniques, especially the PSA test. The summary:

The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years.
Grade: I Statement.

The USPSTF recommends against screening for prostate cancer in men age 75 years or older.
Grade: D Recommendation.

Paul Menzel and I have written about a number of factors which should be involved in recommendations and/or resource allocation associated with prevention screening, and I won’t repeat those items in this blog. I will mention, however, that Diana Petitti’s chapter 5 of our book, Prevention vs. Treatment: What’s the Right Balance?looks at some of those issues as well from a former USPSTF member’s insider view.

A 2-month-old infant died from whooping cough (pertussis) yesterday in New Mexico. It’s unclear how the child was exposed to the disease. It had been vaccinated with its first dose of vaccine, usually given at 2, 4, and 6 months, and then later in childhood several times as well. Recently the Advisory Committee on Immunization Practices has recommended that adults be re-vaccinated for pertussis when they get their tetanus and diphtheria booster shots as well.

Pertussis vaccine is very effective, but immunity wanes after 4-20 years (depending on age of the individual, number of booster shots, etc.). Herd immunity for pertussis requires a high vaccination rate – in the 92-94% range. Since vaccine efficacy is somewhere between 85% and 95% (depending on the study you read), if herd immunity is not reached even those vaccinated (but not with effective immunity) are vulnerable.

Before vaccines were available, for example “from 1926 to 1930, there were 36,013 pertussis-related deaths in the United States. The average death rates from 1940 to 1948 per 100,000 population per year were 64 in children less than 1 year old, 6.4 in those 1–4 years of age, and 0.2 in those 5–14 years of age. More than 90% of the reported pertussis cases occurred in children less than 10 years of age, with about 10% of those in children less than 1 year of age.” (Cherry, 2007) Since vaccination has become available, death rates have dropped to less than 1 per 100,000 population.

The tragedy here is not solely the one New Mexico infant’s life (which I don’t mean to minimize with this commentary). The tragedy is that these deaths are preventable. Now, I’m not one to attribute blame for many things – I find it doesn’t do much good to concentrate on who did something, but more to look at why it happened and how we can correct the situation, including preventing deaths in the future. But in this case it seems clear to me that we have blame to apportion in two arenas: 1. those who don’t vaccinate their children or get their own vaccinations, and 2. our politicians who skimp on public health resources.

1. The unvaccinated are responsible for the death of this infant.
Parents who are irrationally fearful of getting their children vaccinated reduce the population vaccination rates and therefore herd immunity is not obtained. Similarly, adults who don’t get their booster shots are as culpable.

Because immunity is not 100% obtained by 100% of the population being vaccinated, some individuals will be vulnerable to getting pertusis. The only way to prevent those vaccine failures from getting the disease is for the population to reach its herd immunity, requiring at least 94% of the population being vaccinated. Those who don’t get vaccinated (aside from those who have justifiable medical reasons like compromised immune systems from cancer or immune deficiencies) are reducing the probability of herd immunity. They are, in essence, freeloaders – thinking they can avoid the disease while abdicating their responsibility to prevent it for themselves or others.

2. Our state and local politicians (and federal to some extent) are responsible for the death of this infant.
Local and state health departments have been devastated with the reduction in financing during this recession. They have lost 15-25% of their personnel, had to reduce or eliminate 33% of their programs, and have had significant morale problems. They are asked to perform almost all of the functions they were doing before 2008 with many fewer resources. This impacts vaccination rates and surveillance capabilities.

It’s always difficult to point the finger at one fiscal cut and say “that caused this infant’s death.” That’s because people don’t attribute the same kind of cause and effect from indistinct dollars (even if guided to certain programs) and unidentified lives in the community. But there are plenty of philosophical reasons to claim that there is no difference between identified and unidentified lives when it comes to health care expenditures. (Harvard’s Program in Ethics and Health had a 2-day conference on this topic last month.)

But politicians who self-righteously defend program cuts while simultaneously decrying the ineffectiveness of our health care system or public health system are as culpable as freeloading parents who don’t get their children vaccinated, or adults who aren’t re-vaccinated. And now they want to do it again: cutting the Prevention and Public Health Trust Fund to reduce interest rates on college loans.

What about you – are you up-to-date on your booster shot for tetanus, diphtheria, and pertusis? If you are over 60 have you gotten your shingles and pneumococcal vaccines?

Addendum

:
A couple of days after I first posted this item it came to light that the state of Washington declared a pertussis epidemic on April 3rd. Over 1280 cases have been reported as of May 11. The governor of WA “announced the state is putting $90,000 into a public awareness campaign and diverting some federal money to pay for 27,000 doses of vaccine.” Where was the governor in preventing the epidemic in the first place? This gets back to the old question: “Prevention vs. Treatment: What’s the right balance?” Unfortunately, this is another example of prevention not getting its due when it could have been more effective – before the epidemic occurred.

Second addendum:
See the NY Times article today about this outbreak. Here’s the particularly relevant paragraph:

Here in Skagit County, about an hour’s drive north of Seattle — the hardest-hit corner of the state, based on pertussis cases per capita — the local Public Health Department has half the staff it did in 2008. Preventive care programs, intended to keep people healthy, are mostly gone.

For those interested in listening to a one hour talk show interview on Prevention vs. Treatment see Mary Charlotte Domandi’s Santa Fe Radio Cafe from February 6, 2011: http://itunes.apple.com/us/podcast/monday-february-6-2012/id251501948?i=110315265.

In the Wall Street Journal today (January 25, 2012) Archbishop Timothy Dolan argues that the mandate to cover birth control for all Americans, without excluding conscience-driven religious organizations like the Catholic Church, is unfair. He argues that the US Constitution prohibits such mandates on religious institutions.

He admits that the religious exemption included in the Obama rules regarding coverage of birth control would include religious organizations that primarily engage in serving people of their own religion. But Dolan wants a broader exclusion of any employment by any Catholic organization.

My guess is that Dolan will be happy to continue to accept Federal funding for Catholic Family Services and other religiously-based organizations that provide services to non-Catholic families. Such Federal funding generally helps to defray overhead costs for the core mission of such services (Jewish Family Services also benefits from these kind of arrangements in various cities) while providing fee-for-service or contract services to help the needy and indigent.

Apparently the separation of church and state isn’t as broad as Dolan makes it sound. (He also accepts tax-free accommodations for his various real estate and sales activities, tax-free public services like fire and police, etc.) In essence he is saying, “I’m a citizen when I want to be.” While I agree with the right of freedom of religion without interference by the state regarding beliefs and ability to worship, I don’t agree on religion’s being able to pick and choose when it engages and when it doesn’t with the state on its own terms. After all, freedom of religion is a state-given (constitutional) benefit.

But I’m no constitutional scholar, nor an academic on how the church (generically) benefits from its constitutionally-defined separation from federal/state/local citizenship. I would note, however, that the church does follow some other government employment laws and rules and regulations without current constitution-related separation arguments. So they clearly comply when they want to. The question is, what is the right balance of engagement and compliance vs. belief-driven dissonance?

Let’s look at Dolan’s concluding three paragraphs, which is where his logic is incomplete.

In the third-from last paragraph, Dolan states, “Coercing religious ministries and citizens to pay directly for actions that violate their teaching is an unprecedented incursion into freedom of conscience. Organizations fear that this unjust rule will force them to … Stop serving people of all faiths…or stop providing health-care coverage to their own employees.”

This is what ethicists call a moral dilemma: when two (or more)_ options are available, all presumably equally important yet also independent and exclusive (I can’t do two or more actions, only one right now), all of which would be morally right, and a decision must be made. So the church in this case would have to decide: do I act on my principles related to birth control, or on other principles: helping the indigent no matter their religious affiliation; providing fair and just benefits to our employees. OK, a difficult decision if all of these items are equal. This is a true moral dilemma. There are lots of Catholic teachings about the vision of what a Catholic conception of a good society with social justice entails. As Nuala Kenny states in chapter 13 of Prevention vs. Treatment: What’s the Right Balance? :

Dignity of the human person

Social interdependence and social solidarity

Commitment to the common good

Special obligation to the poor and vulnerable

Stewardship of resources

Subsidiarity decisions should be made at level of those most affected.

The church then needs to decide if this concept of social justice for the poor and vulnerable, something they tend to generously through various services they provide to non-Catholics as well as Catholics, is less important for the common good than not providing birth control as a benefit. They could provide the benefit while preaching to their employees that it shouldn’t be used, in order to be in compliance with the federal rules.

In terms of the fair and just dealing with employees, the Church has been out in front of this issue for many years both in the US and abroad. If the church values this then it is hard to see how they would terminate health insurance benefits for their employees. It would have determined that the health and well-being of its employees is less important than its concern about the provision of birth control benefits. It could compensate employees for the foregone costs of health insurance and discontinue the benefit. Employees would then be obligated to purchase health insurance from exchanges or elsewhere, which also would be providing the benefit. This is a reasonable choice for the church, though inconveniencing its employees.

In the second paragraph from the end, the Archbishop states, “…the Obama administration has failed to show the same respect for the consciences of Catholics and others who object to treating pregnancy as a disease.” Indeed in this case the archbishop simply has it wrong – the Obama administration is treating birth control as it should be treated – a preventive measure. This is evident in their stating that there would be no copays or deductibles – operative as a benefit only under the prevention provision of the ACA. For many years women have argued that pregnancy is not a disease. And I think they are right. But preventive measures are not taken only to avoid disease. Such measures are also taken to enhance well-being.

If society is to take social determinants of health and well-being seriously, then they cannot ignore the effects of unplanned pregnancies on such social determinants. And the church cannot simply pick and choose when they wish to do so. So Timothy Dolan and other Archbishops around the country do have what is seemingly a moral dilemma: stick with their opposition to birth control, or stick with their support of the needy and vulnerable, or stick with their support of just and fair employment practices. Which will it be? Are these mutually exclusive? Or will a better, non-exclusive balance be struck?

Addendum 1/27/12:

David Skeel has a short op-ed in the Wall Street Journal discussing this issue regarding how the courts decide many of the issues at stake. In particular he mentions the narrow religious exception permitted under the Obama rule consistent with earlier Supreme Court rulings (Hosanna-Tabor).

When I was a resident my “mentors” did what most physicians do: they taught me how to write-up preventive screening procedures as diagnostic or therapeutic ones so that they (and the patients) could get reimbursed by insurers. So, a screening mammogram to detect early breast cancer, which wasn’t covered in the 1970s and 1980s in most insurance contracts, was written as “mass, rule-out cancer” or a screening resting EKG (which we now know is of little value) was recorded as “chest pain, rule-out ischemic heart disease.”

Surveys of physicians done by reputable researchers in the late 1980s and repeated in the late 1990s/early 2000s showed many physicians knowingly coded screening procedures fraudulently (see for example JAMA 1989;261(20):2980-85; JAMA2000;283(14):1858-1865). In the 1989 survey the researchers found that,

The majority [of physicians] indicated a willingness to misrepresent a screening test as a diagnostic test to secure an insurance payment…Most physicians indicated a willingness to engage in deception in some circumstances, justifying their decisions in terms of the consequences and placing a higher value on patient welfare and keeping confidences than on truth telling.

In the 2000 article, Wynia, et. al. concluded that:

A sizable minority of physicians report manipulating reimbursement rules so patients can receive care that physicians perceive is necessary.

Now the tables have turned. The health reform act (known as the Accountable Care Act, or ObamaCare) has a provision that requires prevention procedures to be covered at 100% without a co-pay or deductible.

Secondary prevention is the use of screening procedures like colonoscopy to detect existing disease before it has signs or symptoms (see Prevention vs. Treatment: What’s the Right Balance? pages 12-13 for more details). This preventivescreeningprocedure means that something is being done without a suspicion of existing irregularity – cholesterol is being checked to see if it is abnormal (not because it’s been abnormal and the patient wants to see if treatment has brought it down), or a colonoscopy is being done when there are no symptoms or signs that would suspect colon cancer (not because of an already established positive blood stool test, or presence of previous polyps, or prior diagnosis of colon cancer).

So physicians can get rid of their deceptive practices of old and request the procedure for what it is. Let’s hear it for the system now encouraging moral integrity for physicians! At least given old practices.

Covering new benefits, of course, costs more money for insurance plans, which will have to raise premiums to cover these new benefits. If the actuaries for insurers haven’t already raised the premiums (or requested raises, which the state insurance commissioners may have nixed or reduced), then no pity on them – they had fair warning. But presumably they have factored these newly covered benefits into their premiums, so now, as reported by the AP (see here), they are simply gaming the system the way physicians have for years.

In my experience in the health insurance industry in the 1980s and early 1990s we found many physicians gaming the system in many ways – up-coding procedures, mis-coding procedures, splitting (unbundling) what should have been bundled procedures, mis-dating follow-ups so they didn’t look as if they were for bundled payments, etc. At the same time, reputable insurers tried to administer health insurance contracts quickly and fairly. At Aetna, where I was medical director of the claims department, we prided ourselves on clearing claims very rapidly. Where there were questions, we attempted to review and adjudicate the claim as soon as information was received to clarify the questions. 98-99% of all claims were paid without question. But on a claims base of millions a day, 1-2% would still kick out >1500/ day. Not all of these were medical issues, sometimes they were contractual benefits or eligibility ones which were handled by other departments.

Certainly we heard of irreputable insurers in the business, looking for ways not to pay claims. But that wasn’t our culture. I’ve been out of the health insurance business for 21 years, so things may have changed. (OK, please don’t write in about your individual claim problem. We’ve all had disappointments with one or more claims if we’ve lived long enough and submitted enough claims to health insurers.)

I’m not trying to be an apologist for insurers – I know they can be frustrating and difficult to deal with sometimes. And certainly what they are doing now – changing the definition of a screening procedure to a diagnostic one because of findings from a screening procedure – seems deceitful.

My advice to individuals who experience this is to be sure that (a) your physician writes clearly that the requested procedure is for screening, (b) the screening requested is clearly within the guidelines of the US Preventive Services Task Force A or B recommendations, (c) you be vocal and proactive in talking with the insurer and provider in advance, and (d) if you get a billing surprise, appeal the decision as many times and layers as necessary.

So while the patient is asking for fair play from the insurer, at the same time the insurer is asking for fair play from the doctor and patient – don’t misrepresent the purpose of the test as screening if indeed it is diagnostic because of pre-existing symptoms or signs. In that case the bait and switch isn’t the insurer’s fault, but the patient’s and doctor’s. We all need fair play – honesty, not manipulation – in health care.

The argument Kliff looks most at is related to the table Russell shows (figure 3.1) by Joshua Cohen, et. al. that appeared in the New England Journal of Medicine in 2008. According to Google Scholar this article has been cited 195 times since its publication.

It seems to me there is one problem with Cohen, et. al.’s article: it lumps together apples and oranges in its comparison. To compare all well-defined studies of prevention with all well-defined studies of treatment ends up comparing such disparate items as genetic screening for inborn errors of metabolism and surgery for elderly men with prostate cancer. On a macro basis this may be the best we can do when asking the economic question of prevention vs. treatment. But such comparisons seem besides the point when mixed together. I’d rather see comparisons of like-minded prevention and treatment. For example, how does preventive statin use compare with coronary artery bypass surgery? Or more broadly, how does screening and reduction of risk factors for heart disease compare with treatment of preventable heart disease?

A discerning eye can see that prevention cannot impact all types of heart disease, e.g., already established unexplainable congenital heart defects, or right heart failure due to hereditary chronic lung disease. Many (perhaps most) diseases we find in medical textbooks do not have easily defined causes which can be short-circuited by prevention maneuvers. Just as we cannot prevent a disease in a non-at-risk population (i.e., a population that cannot get the disease in the first place – men don’t get ovarian cancer; women who’ve had total hysterectomies cannot get uterine cancer), we cannot prevent a disease for which we do not know predisposing risk factors or causative agents.

[Let me be clear that this doesn’t mean we can’t prevent disease without knowing its proximate cause. Scurvy was prevented in sailors without knowing about vitamin C per se; it was prevented by an observation of the relationship of the lack of citrus fruits and the profound spread of scurvy among sailors. In this case citrus fruits were a surrogate for the active vitamin C ingredient. There are many other such examples in the history of preventive medicine. See, for example. Burt Gerstman’s Epidemiology Kept Simple, 2003, p 290]

One other problem with the cost-effectiveness analyses typically done: they discount the value of future lives. This almost automatically puts prevention at a disadvantage because by definition the effects of prevention are in the future, while the effects of treatment are usually gained in the short-term. So for every life saved in treatment this year, we would need two or more lives saved in the future through prevention if we discount lives. This has interesting ethical implications, the most obvious of which is: why is a life in the future worth less than a life right now? Menzel explores this issue in detail in chapter 11 of Prevention vs. Treatment and I won’t recount his discussion here other than to say that the economic rationale of discounting monetary value most likely doesn’t hold for the value of life, especially when an ethical analysis is done. Because we make health policy including not just dollars but also values, this may hold a very telling modification of the policy implications of Russell’s analysis.

Making health policy involves many different aspects of life: scientific evidence of a highly predictive diagnostic test, reasonable price, competing resource demands, comfort and convenience of a test, seriousness of the disease being detected, impact of the disease on the individual and the population, etc.

Anyone who’s been involved in health policy debates will recognize that, except for predictive value of the test and actual cost of the test, both of which can be determined somewhat objectively, all of the rest of the items listed above are laden with values (and one can argue even arriving at the predictive value involved significant calls on various values in doing the studies). Evidence-based medicine only provides information, it doesn’t provide a support of values and how they will be applied in society.

Rather than reproduce some of the less-than-obvious arguments about screening for prostate cancer here, those interested can find more information in Paul Menzel’s and my recent posting on the Oxford University Press blog website.

Joe Palazzolo is a reporter for the Wall Street Journal. On November 8, 2011 he reported on the legal issues related to the Penn State scandal. In his article, “Child-Abuse Reporting Law is Challenge to Prosecutors” he states:

Some observers wonder why lying to a grand jury about knowledge of child-abuse allegations carries a stiffer punishment than failing to report them in the first place.

This is, to some extent, a parallel issue to why we prioritize treatment over prevention. If there is any doubt that we do, read chapter 1 of Paul Menzel’s and my recently published text, Prevention vs. Treatment: What’s the Right Balance? (Oxford University Press, 2011).

To answer Palazzolo’s quandary, in essence we consider breaching trust in testimony more harmful to society than preventing harm to children. The first preserves the integrity of our society. The second should preserve the integrity of individuals. Sometimes we prioritize one over the other, sometimes not.

Note that this is an explanation of how society has made legislation, not a justification. Most legislation is made linearly, not comparatively. Nobody sat down and said, “Is child abuse more or less important than lying?” The juxtaposition of the two occurs now because of the peculiar circumstances and conditions of the Penn State case. Is it the right balance? Will the Pennsylvania legislature see this juxtaposition and take action to either reduce penalties for perjury, or increase penalties for failing to report child abuse? Only those in Pennsylvania who vote and could put pressure on their legislatures will determine that question. It would be interesting to know, however, if the same relative penalties exist in most other states. Any lawyers out there who can research the questions?

Like this:

Carl Bialik’s column in the Wall Street Journal this past weekend (Nov. 12, 2011) discusses the “Income Ladder’s Sticky Steps.” He tackles the difficult question of assessing mobility, showing how defining the strata may change the conclusions that can be reached, including issues such as (1) What age groups should be included? (2) How do you handle natural progress of careers; older employed folks usually make more than they did when they were younger because their careers progress? (3) Would we be better tracking longterm earnings, as there can be natural fluctuations from year-to-year?

These have important implications when trying to look at economic progress. For example, the Occupy Wall Street folks claim they are the 99% who are below the chasm of the 1% highest earners. Of course they are – the 99 out of 100 people will be in the 99% by definition. Except for celebrity guests of the Occupiers (who likely are in the 1%), those with the time on their hands to protest will be in the 99%.

Bialik states, without making further comments, “And none of the income measures explicitly includes wealth, which is distributed more unequally than income.” This is an important statement. Bialik is not the only one who recognizes but does not deal with the issue of wealth. In Conflicts of Interest in medicine and health care wealth is at least partially ignored. How?

Most conflict of interest disclosure requirements for authors in journals or speakers in continuing medical education events include provisions to disclose relationships with companies or other interests.

The International Committee of Medical Journal Editors states: “Conflict of interest exists when an author (or the author’s institution), reviewer, or editor has financial or personal relationships that inappropriately influence (bias) his or her actions (such relationships are also known as dual commitments, competing interests, or competing loyalties).”

2.1 The provider must be able to show that everyone who is in a position to control the content of an education activity has disclosed all relevant financial relationships with any commercial interest to the provider. The ACCME defines “‟relevant‟ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

How does this normally exhibit itself in CME speaking activities? In my experience the moderator of a session will state “so-and-so discloses that (s)he owns stock in [Drug] Company” or “so-and-so discloses that she has been paid an honorarium by [Device] Company” and it is left at that. As we know, disclosure doesn’t fix the conflict, it merely reveals it. Loewenstein notes related to the physician-patient relationship,

Disclosure may give the adviser a “moral license” for strategic exaggeration in the adviser’s best interest. (“I told her I had a conflict—now, I can recommend the surgery.”) Having disclosed a conflict of interest, moreover, advisors may feel compelled to give advice in an extra-forceful fashion.

This may be similar for the speaker-audience relationship, “I [the speaker] have disclosed my conflict, now I needn’t worry about it, or I may feel free to discuss it even more than if it were hidden.”

However, the key question that needs disclosure is “What does this relationship mean to the speaker and how has it influenced his/her presentation of information?” Simply knowing that someone has been paid an honorarium or owns stock in an enterprise doesn’t tell the audience if such ownership is meaningful. More importantly, what does that represent in terms of one’s income or wealth? If the speaker has net worth of $100 million, owning $10,000 of stock likely is relatively meaningless. On the other hand, if the speaker’s net worth is only $200,000, that $10,000 of stock may be critical for how she wants to please either the commercial interest (to get more stock or honoraria) or the audience (to purchase more of the product offered by the commercial interest).

(As an aside, at a recent Harvard University Program in Ethics and Health conference conditional cash transfer payments to encourage health promoting activities in second world countries was discussed. As I recall, levels of payments had to approach 20-30% of annual income to get behaviors to change substantially. This, of course, differs from findings related to physician behavior, which is influenced by small pharmaceutical company gestures.)

So, while ignoring wealth as the denominator of disclosure is usually done, we should consider the issue as a much more important measure. Further there likely is some interactive relationship between meaningful financial ownership (wealth) and income. Income fluctuations may have little meaning if the amounts are small, or if one has equilibrium with a lifestyle that is fully supported by drawdowns on existing wealth (not requiring additional annual wealth through income or increases in, for example, stock value).

Because of the complexity of the interaction of wealth, income, and meaningful bias/influence the leading medically-related institutions are moving to requiring disclosure of any financial relationship between an author/speaker/influencer and a commercial interest. This makes sense, in that research indicates that we often don’t let data get in the way of our biases, which can easily come from financial self-interest, and that even small conflicts can result in unconscious bias. Until we have more reliable data on the relationship between wealth and income this is probably prudent, but also recognizably excessive.

How to find the right balance? More easily done when more research is completed.